Babies Mixed Up

Babies Mixed Up; Front-Line Staff Botches Communication with Parents

Well-known author Karin Tanabe recently delivered a healthy baby girl in Sibley Memorial Hospital in Washington, DC — and then the hospital gave her baby to another mother and the front-line staff did not know how to handle the situation. Training front-line staff how to handle adverse events is critical, and we have so much work to do in this area at hospitals and nursing homes across the country. Ms. Tanabe wrote an essay about her experience for the Washington Post, and this article should be both enlightening and scary for hospital and nursing home administrators. Here are some of my favorite highlights from Ms. Tanabe’s column:

First nurse causally tells Ms. Tanabe and her husband their newborn will receive a jaundice test this morning, and, oh by the way, she was given to the wrong mother this morning. The nurse went on to explain that another nurse had committed the mistake, but corrected the situation before the wrong mother even touched the child. No biggie!

Ms. Tanabe was initially OK with the flippant explanation, but then questions and fears set in (did the wrong mother have Ebola?!?), so her husband elevated the situation. A more senior nurse came to their room (but only because Ms. Tanabe’s husband requested) and this second, more senior nurse had a different story: The wrong mother held the baby and fed the child formula, but, it was kinda the wrong’s mother fault because the numbers on the bracelets were similar and the wrong mother should have caught the mistake, but, not to worry, the hospital lawyers have been contacted! Huh?

Ms. Tanabe’s husband was able to find the “wrong mother,” and Ms. Tanabe and this woman had a chance to talk — and the wrong mother showed Ms. Tanabe that her ID bracelet was a completely different number, not one digit off has nurse #2 had indicated.

On the way out of the hospital, Ms. Tanabe requested that the incident be recorded in her daughter’s medical record and that she and her husband be allowed to see a copy of the incident report. Neither has happened. The couple did receive a phone call from the hospital with a promise to follow up, which never happened! As the Gomer Pyle would say, “Surprise, surprise, surprise!”

So, Ms. Tanabe — being a professional writer — decided to write an article about her incident, and then things started moving. The hospital apologized, invited Ms. Tanabe to sit down with physicians to discuss the incident, and eventually showed her the changes that have been made (or are being made) to make sure this event doesn’t happen again.

Wow, what a story…and what an opportunity for other hospitals to learn. And I’m not just talking OB staff. Adverse events happen everywhere in hospitals AND nursing homes, and front-line staff need to know how to empathize at the bed side, tell the truth and not get caught in lies without prematurely admitting fault, and elevate the situation so senior leadership can properly work with the family. This story has multiple communication failures, including my personal pet peeve: Promising to follow up with the family, but not doing so. Big NO, NO! Moral of the story: Patients and families shouldn’t have to be well-known authors to get answers and a humane resolution. Front-line staff and leadership should be trained to make it happen with every case.